Starting from a single-sided thoracoscopic procedure with a monopolar energy source on the beating heart, we were initially confronted with the surgical and technical limitations of the ablation devices and the procedure. A simultaneous endocardial approach seemed mandatory to understand the limitations of our minimally invasive approach. Initially setting up this collaboration with the electrophysiologist was challenging. Some

of the obstacles we had to overcome were: trying to understand our common goals, organizing the availability of the different multidisciplinary teams, criteria for selection of patients, deciding where Inhibitors,research,lifescience,medical the procedure should be performed, and the sequence Inhibitors,research,lifescience,medical of the procedure. Evaluation of our findings acutely and over time

has made necessary several changes to our approach and choice of ablation technologies and devices. This could only be achieved through a genuinely open-minded team approach that remained critical regarding the achieved success and also a willingness to take a retrospective view to compare this new approach to other more standard procedures. SINGLE-SESSION HYBRID PROCEDURE VERSUS PERCUTANEOUS CATHETER ABLATION The reported success rate of percutaneous catheter ablation Inhibitors,research,lifescience,medical of paroxysmal atrial fibrillation with a single procedure ranges from50% to 80%.These results are even lower for patients with persistentatrial fibrillation (30% to 50%). The differences in success rates could be explained by a variety of reasons, including the experience of the center, the ablation strategy, the technology, the follow-up criteria, and other variables. A major concern is the significant recurrence rate after

Inhibitors,research,lifescience,medical initial complete GDC 973 pulmonary vein electrical isolation, necessitating repeat interventions Inhibitors,research,lifescience,medical to achieve long-term cure of atrial fibrillation (even in high-volume centers). Recovered pulmonary vein conduction after initial acute circumferential pulmonary electrical isolation is the dominant rationale for recurrent atrial fibrillation and atrial tachyarrhythmias.15 The problem of durability of contiguous and transmural ablation lines in percutaneous transvenous endocardial procedures is related to multiple factors: the procedure is performed with the help of virtual imaging (fluoroscopy and three-dimensional mapping) Resminostat limiting actual anatomical accuracy; the permanent tissue effects of ablation will depend on adequate and stable catheter tip to tissue contact; and the actual necessary parameters of energy delivery are difficult to define in an environment of circulating blood. These issues can be addressed by epicardial application of a bipolar radiofrequency clamping device and should therefore result in more consistent antral lesions and isolation of the pulmonary veins. With an epicardial approach, direct anatomical visualization and stable device tip to tissue contact are obtained.